Surgical approaches to the orbit. Indications and techniques

An integrated fuzzy neural network model for surgical approach selection using double hierarchy linguistic information

The selection of the most effective surgical approach is a critical decision in major surgery. With several approaches available, it is important to select the one that will have the most beneficial effect on the patient's health. Multi criteria decision making techniques are essential for identifying the most effective surgical approach to optimize patient health. Therefore, we develop a two novel decision making models under the double hierarchy linguistic information to select the best surgical approach for patient health. A more flexible way to express uncertainty and fuzziness in the surgical approach information is possible using the double hierarchy linguistic term set, which is made up of the first and second hierarchy linguistic term sets. Initially, we discuss the double hierarchy linguistic term set and its aggregation operator based on the Aczel-Alsina norms, as well as some basic properties of the Aczel-Alsina aggregation operator under the double hierarchy linguistic term sets. Next, we develop two novel decision making models under double hierarchy linguistic information, known as the WASPAS method and the double hierarchy linguistic neural network with the Aczel-Alsina aggregation operator. After that, we apply the proposed decision making models to select the most effective surgical approach to optimize patient health. For this, we collect the information about the surgical approach from the three highly qualified experts of the surgical approach. Further, we follow the procedure of the proposed models to compute the final output and select the most effective surgical approach to optimize patient health. After that, we evaluate the sensitivity of the proposed models in the context of surgical decision making. Moreover, we evaluate the validity and efficiency of the proposed decision making models by comparing them with existing decision making models.

Superior orbital rim grinding as a novel surgical technique to approach superior and posterior orbital tumors

PURPOSE

To describe a novel surgical technique aimed to approach those orbital lesions located superior and posterior to the equator of the globe.

METHODS

We describe a novel surgical technique that was performed in four patients to approach intraorbital tumors superiorly and posteriorly located. This technique was completed through an upper eyelid skin crease followed by grinding the superior orbital rim to achieve complete removal of the lesions.

RESULTS

Complete removal of the lesion was accomplished in every case. No intraoperative complications were observed in any of the patients. During the follow-up period, one patient presented with frontal hypersensitivity and one with diplopia.

CONCLUSIONS

In the case series presented, the upper eyelid skin crease approach with grinding of the superior orbital rim proved to be a safe and effective surgical technique to remove lesions located superior and posterior within the orbit in our series. More studies are needed to further evaluate the efficacy and long-term results of this approach.

Anatomy of the medial wall of the orbit undergoing an endoscopic endonasal approach: An inferomedial and superomedial approach

Background

Endoscopic endonasal corridor is valuable for accessing and treating midline skull base pathologies. In the present work, we will discuss the anatomy of the medial wall of the orbit from an endonasal endoscopic perspective.

Methods

Six human cadaveric specimens underwent endonasal endoscopic dissection at the Surgical Neuroanatomy Laboratory of the Mexican Faculty of Medicine of La Salle University. We used a 0°, 4 mm diameter, and 18 cm length rigid endoscope using a 4K high-definition neuro-endoscopic visualization system, specialized surgical instruments for endonasal endoscopic surgery, and a high-speed drilling system.

Results

In the endonasal endoscopic to the medial wall of the orbit, we describe two approaches: the superomedial approach (SMA) and the inferomedial approach (IMA). The SMA is located between the lower border of the superior oblique muscle and the superior border of the medial rectus muscle (MRM), and the IMA is located between the inferior border of the MRM and the superior border of the inferior rectus muscle. The topographic anatomy of the contents of each approach is described.

Conclusion

The endoscopic endonasal corridor safely reaches the medial half of the orbit through the inferomedial and SMAs.

A retrospective analysis of the management and surgical treatment of orbital lesions: Outcomes and rationale

The orbital cavity is a subject of interest for various specialists, and achieving optimal outcomes requires comprehensive, multidisciplinary management. This study aims to report 10 years of experience in the preoperative, surgical, and postoperative care of patients with orbital lesions, examining their clinical, radiological, and anatomopathological features and outcomes. A retrospective review of 125 patients who underwent surgical treatment for intraorbital masses between January 2012 and December 2021 was performed. Outcome measures included postoperative diplopia, exophthalmos, decimal visual acuity, eyeball position, ocular motility, operative time, complications, and aesthetic results. A total of 107 patients were included. All cases were discussed with a neuroradiologist to determine the best therapeutic approach based on preoperative imaging. Preoperative diplopia was linked to extraconal (p = 0.03) and anterior (p = 0.001) lesions, and exophthalmos and visual acuity deterioration were associated with intraconal (p = 0.02; p = 0.03) and retrobulbar (p = 0.001; p = 0.02) lesions. Complications (11.2%) included diplopia, worsened visual acuity, postoperative blepharoptosis, and postoperative ectropion. Of the patients, 80.4% reported an "excellent" aesthetic outcome. This study underscores the importance of a multidisciplinary approach based on a thorough analysis of preoperative imaging. Periorbital approaches tailored to the lesion's three-dimensional location enables safe access to most intraorbital lesions, resulting in minimal complications and good aesthetic results.

Clinical anatomy of the spina musculi recti lateralis: A frequently overlooked variation of the greater wing of the sphenoid

BACKGROUND

The spina musculi recti lateralis (SMRL) is often visible along the lateral rim of the superior orbital fissure (SOF). Aim of this study is to characterize SMRL morphology and topography relative to known bony landmarks.

METHODS

Orbits from 291 adult dry skulls and from 60 CT scans were analyzed to measure the distance between the SMRL and the SOF or the inferior orbital fissures (IOF) as well as its height, width and orientation. Processes other than SMRLs were also recorded. Fetal skulls were observed for comparison with adult samples.

RESULTS

Forty-one per cent of orbits on dry skulls and 43.3% by CT showed an SMRL. Additional 32.9% of orbits on dry skulls had processes with a different shape. On average, SMRL were orientated almost along the transverse plane and showed implant bases as wide as 141.9° or as narrow as 36.8°. SMRLs were close to the infero-posterior angle of the orbital plate of the sphenoid, 1.21 ± 0.84 mm in front of the SOF, 5.8 ± 1.9 mm above the IOF and 12 ± 2.3 mm from the anterior end of the SOF. They were 1.58 ± 0.64 mm high and did not show any age or sex-related prevalence. By CT, the SMRL appeared as the insertion site for the lateral rectus, tendinous ring and, sometimes, inferior rectus.

CONCLUSIONS

The SMRL is a process of the sphenoidal orbital plate rather than of the SOF. It is also a reliable landmark for the insertion of the tendinous ring and lateral rectus. Orbital surgeons should be aware of this common variant of the orbital apex.

Navigational Transmaxillary Endoscopic Approach for Inferomedial Tumors

Orbital tumors encompass a heterogeneous range of histopathology and usually variable in location. Traditionally, transconjunctival medial orbitotomy is used to access the medial orbital wall. However, it creates potential risk of soft tissue sequelae such as scarring, lid contracture, or entropion/ectropion. For the lesions close to the orbital apex, increased risk of optical nerve injury should be cautious during orbitotomy procedure. Transnasal endoscopic approach to the orbital walls has been applied since 1999. Although it provides good surgical visualization and prevents the soft tissue and neural complications, the narrow nasal corridor increases the surgical complexity. Extensive sphenoethmoidectomy is usually required to gaining access. Furthermore, the resultant medical orbital defect is difficult to repair. The maxillary sinus is the largest paranasal sinuses which is located beneath the orbital floor. It provides an ample working space for instrumentation. Meanwhile, repair of the orbital floor defect is feasible and with high degree of accuracy under navigation control. In this report, we propose a novel computer-assisted endoscopic protocol to excise the medial orbital tumors with immediate repair of the wall defect.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit

Introduction  Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods  Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results  EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion  EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Repair of the orbital floor fractures: The endoscopic trans-maxillary approach as minimally invasive approach: A case-report

INTRODUCTION

The endoscopy in orbital surgery provides, similar to other surgical fields, the option of combining an extended view of the surgical field with minimally invasive approaches; also allows an excellent functional and esthetic results. Trans-maxillary endoscopy of the orbital floor offers excellent visualization of the posterior bony shelf and confirms that the implant rests securely in place.

PRESENTATION OF CASE

The authors report a ten years-old male child, reported to the oral and maxillofacial surgery department, Ibn Rochd university hospital, Casablanca, Morocco. The child was diagnosed for left orbital floor fracture, complaining of orbital trauma due to road accident. The injury occurred at the left orbit level. There was no general story of any disease.

DISCUSSION

In more than 40% of all the facial fractures parts of the orbital rim or/and the internal orbit are injured with a variety of fracture patterns. Accurate assessment is required in order to correct any bone defects or displacements. The surgical approaches have become more reduced offering better control of orbital pathological processes. Orbital lesions are precisely localized through imaging. Also, the approach decision depends on location, size and vascularization. No consensus exists regarding the timing of the repair, the repair technique and the optimal implant. In this case presentation, the defect on the orbital floor was extended by mobilization of the fragments. A combination of incisions was necessary due to the change in the dimensions of the defects intraoperatively and entrapment of orbital tissue by the placement of an implant.

CONCLUSION

The endoscopic approaches provide excellent visualization and safe from eyelid complications with no visible scar when secondary open fracture reduction is avoided. Also; the rate of postoperative complications are reduced: optic nerve injury, orbital apex injury.

Endoscopic sublabial transmaxillary approach to the inferior orbit: pearls and pitfalls-A comparative anatomical study

OBJECTIVE

Although orbital surgery has always represented a challenge for neurosurgeons, keyhole and endoscopic techniques are gradually surging in popularity maximizing functional and esthetic outcomes. This quantitative anatomical study first compared the surgical operability achieved through three endoscopic approaches within the inferior orbit: the endoscopic sublabial transmaxillary (ESTMax), the endoscopic endonasal transethmoidal (EETEth), and the endoscope-assisted lateral orbitotomy (ELO).

METHODS

Each of these approaches was performed bilaterally on five specimens. We described the ESTMax step-by-step, underlining its advantages and pitfalls in comparison with EETEth and ELO. Then, we assessed surgical measurements and operability in ESTMax, EETEth, and ELO.

RESULTS

The ESTMax provided the most favorable operative window (278.9 ± 43.8 mm²; EETEth: 240.8 ± 21.5 mm², p < 0.001; ELO: 263.1 ± 19.8 mm², p = 0.006), the broadest surgical field area (415.9 ± 26.4 mm²; EETEth: 386.7 ± 30.1 mm², p = 0.041; ELO: 305.2 ± 26.3 mm², p < 0.001), surgical field depths significantly shorter than EETEth (p < 0.001) but similar to ELO, the widest surgical angles of attack (45°-65°; EETEth: 20°-30°, p < 0.001; ELO: 25°-50°, p < 0.001), and the greatest surgical mobility areas (EETEth: p < 0.001; ELO: p < 0.001). Furthermore, the ESTMax allowed multi-angled exposure and handy maneuverability around all the inferior intraorbital targets. Small anterior antrostomy, blunt intraorbital dissections, direct targets' approach, orbital floor reconstruction, and maxillary bone flap replacement may limit the ESTMax morbidity rates.

CONCLUSIONS

The ESTMax is a minimally invasive "head-on" orbital approach that exploits endoscopic surgery advantages avoiding the cranio-orbital and trans-nasal approach limitations and possible complications. It represents a promising alternative to EETEth and ELO because of its optimal operability for resecting lesions extending into the entire inferior orbit.

Orbital Surgery: Evolution and Revolution

This article traces the development of orbital surgery and its subsequent modifications. It also points out the importance of defining one's goal before embarking on orbital surgery. Although generally considered part of ophthalmology, surgery on the orbit has been relatively neglected and not routinely practiced. This article reviews the history of development of orbital surgery, both the revolutionary ideas and the evolutionary changes. There are multiple orbital lesions that do not need to be treated with surgery at all. These days chemotherapy, radation therapy, or even immunotherapy may be more appropriate. The most common orbital pathology, that is thyroid orbitopathy, the physician needs to decide whether or not the orbit needs to be decompressed or whether there are problems related to motility that can be dealt with by eye muscle surgery.

Mini Fronto-Orbital Approach: "Window Opening" Towards the Superomedial Orbit - A Virtual Reality-Planned Anatomic Study

BACKGROUND

Surgical approaches to the orbit are challenging and require combined multispecialist skills. Considering its increasing relevance in neurosurgical practice, keyhole surgery could be also applied to this field. However, mastering a minimally invasive approach necessitates an extended learning curve. For this reason, virtual reality (VR) can be effectively used for planning and training in this demanding surgical technique.

OBJECTIVE

To validate the mini fronto-orbital (mFO) approach to the superomedial orbit, using VR planning and specimen dissections, conjugating the principles of skull base and keyhole neurosurgery.

METHODS

Three-dimensional measurements were performed thanks to Surgical Theater (Surgical Theater© LLC), and then, simulated craniotomies were implemented on cadaver specimens.

RESULTS

The mFO approach affords optimal exposure and operability in the target area and reduced risks of surrounding normal tissue injuries. The eyebrow skin incision, the minimal soft-tissue retraction, the limited temporalis muscle dissection and the single-piece craniotomy, as planned with VR, are the key elements of this minimally invasive approach. Furthermore, the "window-opening" cotton-tip intraorbital dissection technique, based on widening surgical corridors between neuromuscular bundles, provides a safe orientation and a deep access inside the orbit, thereby significantly limiting the risk of jeopardizing neurovascular structures.

CONCLUSION

The mFO approach associated to the window-opening dissection technique can be considered safe, effective, suitable, and convenient for treating lesions located in the superomedial orbital aspect, up to the orbital apex.

Surgical Outcomes of Intraconal Cavernous Venous Malformation According to Their Location in Four Right-Angled Sectors

The present study evaluated the surgical outcomes of intraconal cavernous venous malformation according to their location in 4 right-angled sectors. Data regarding the surgical method and approach, surgical outcome, and postoperative complications were retrospectively analyzed for 18 patients with intraconal cavernous venous malformations that were surgically treated at the authors' center between March 2006 and May 2017. The lesion location was defined using 2 perpendicular lines connecting the optic disc and the 4 surrounding rectus muscles in the coronal plane, which resulted in the formation of 4 right-angled sectors (upper-outer quadrant, upper-inner quadrant, lower-inner quadrant, and lower-outer quadrant). Accordingly, there were 3, 3, 8, and 4 lesions in the upper-outer, upper-inner, lower-outer, and lower-inner quadrants, respectively. Ten patients received anterior orbitotomy and 8 received lateral orbitotomy. There were no recurrences during the follow-up period. All patients exhibited reduced proptosis after surgery. Vision improved in 4 patients and remained unchanged in 14. Five patients experienced ocular movement limitation (1 permanent and 4 temporary), 1 developed an inferomedial blowout fracture, 2 developed a temporary sensory deficit, and 1 developed temporary ptosis. The authors' findings suggest that intraconal cavernous venous malformations most frequently occur in the lower-outer quadrant. Although most lesions can be removed via anterior orbitotomy, large lesions located near the orbital apex or on the orbital wall require lateral orbitotomy. Ocular movement limitation is a common complication and can become permanent in rare cases, necessitating close monitoring. Lesion location and surgical approach do not seem to influence the postoperative complication rate.

Clinical and ophthalmological outcome of endoscopic transorbital surgery for cranioorbital tumors

OBJECTIVE

Cranioorbital tumors are complex lesions that involve the deep orbit, floor of the frontal bone, and lesser and greater wing of the sphenoid bone. The purpose of this study was to describe the clinical and ophthalmological outcomes with an endoscopic transorbital approach (TOA) in the management of cranioorbital tumors involving the deep orbit and intracranial compartment.

METHODS

The authors performed endoscopic TOAs via the superior eyelid crease incision in 18 patients (16 TOA alone and 2 TOA combined with a simultaneous endonasal endoscopic resection) with cranioorbital tumors from September 2016 to November 2017. There were 12 patients with sphenoorbital meningiomas. Other lesions included osteosarcoma, plasmacytoma, sebaceous gland carcinoma, intraconal schwannoma, cystic teratoma, and fibrous dysplasia. Ten patients had primary lesions and 8 patients had recurrent tumors. Thirteen patients had intradural lesions, while 5 had only extradural lesions.

RESULTS

Of 18 patients, 7 patients underwent gross-total resection of the tumor and 7 patients underwent planned near-total resection of the tumor, leaving the cavernous sinus lesion. Subtotal resection was performed in 4 patients with recurrent tumors. There was no postoperative CSF leak requiring reconstruction surgery. Fourteen of 18 patients (77.8%) had preoperative proptosis on the ipsilateral side, and all 14 patients had improvement in exophthalmos; the mean proptosis reduced from 5.7 ± 2.7 mm to 1.5 ± 1.4 mm. However, some residual proptosis was evident in 9 of the 14 (64%). Ten of 18 patients (55.6%) had preoperative optic neuropathy, and 6 of them (60.0%) had improvement; the median best-corrected visual acuity improved from 20/100 to 20/40. Thirteen of 18 patients showed mild ptosis at an immediate postoperative examination, all of whom had a spontaneous and complete recovery of their ptosis during the follow-up period. Three of 7 patients showed improvement in extraocular motility after surgery.

CONCLUSIONS

Endoscopic TOA can be considered as an option in the management of cranioorbital tumors involving complex anatomical areas, with acceptable sequelae and morbidity.

Cranio-Orbital Tumors: Clinical Results and A Surgical Approach

Objectives:

In this study, we aimed to share the surgical approaches and clinical experiences of cranio-orbital tumors, which are surgically difficult anatomies.

Methods:

A total of 22 orbital tumors with extraorbital-transcranial pathology between January 2004 and December 2017 were retrospectively reviewed. Information was obtained from hospital, operation and outpatient records for this study. Preoperative demographic data, ophthalmologic examination findings, clinical and radiological findings were recorded. All patients had cranial magnetic resonance and cranial computerised tomography examinations at this time. The location of the tumor, its size and its relation to neighboring structures were recorded in the light of these examinations.

Results:

The lateral approach was performed in 12 cases. The lateral approach was performed with frontotemporal craniotomy. Because of the lateral inferior location of the tumor in three of 12 cases, zygoma osteotomy was added to classical osteotomy. In 10 cases, the anterior approach was applied and the frontal craniotomy was found sufficient in seven cases. In three cases subfrontal craniotomy was added to classical craniotomy.

Conclusion:

The findings obtained in this study suggest that high resection rates can be achieved with appropriate surgical intervention in orbital tumors requiring a transcranial surgical approach. The most important factor in surgical planning is the location of the tumor. The size of the tumor and the expectation of the percentage of surgical removal are the other important factors. In our series, it has reached high excision ratio in most cases with low complication rate, good visual field and eye movements results.

Surgical anatomy of the orbit. A systematic and clear study of a complex structure

BACKGROUND AND OBJECTIVE

The orbit is a structure of interest for many medical specialties. Surgical approaches to the orbit present significant difficulties for the general neurosurgeon. Whoever decides to practice orbital surgery must have vast anatomical knowledge of this structure. However, although many of the existing publications about orbital anatomy show the complexity of this structure in detail, they fail to facilitate their understanding. The purpose of this study was to systematise and simplify the anatomical study of the orbit from a surgical perspective, to facilitate its understanding.

MATERIALS AND METHODS

A review of the international literature on the subject was carried out, and the principle of the rule of 7was followed for its ordering. For illustration purposes, photographs of cadaveric preparations and digital drawings were used.

RESULTS

The orbits are 2cavities located symmetrically on both sides of the nose. They have a pyramidal shape, with 4sides, a posterior vertex, an anterior base and their axis established from the sagittal plane at a 20-degree angle. A distinctive feature of the orbit is that its elements are organised into groups of seven: 7bones, 7intraorbital extraocular muscles and 7nerves.

CONCLUSION

A systematisation of the orbital anatomy was performed with clear illustrations to simplify its study. The understanding of the anatomy of the orbit is vital to classify lesions and provides a solid basis when choosing the most appropriate approach for their treatment.

[The transpalpebral keyhole approach in surgery of orbital cavernomas: a case report and literature review]

AIM

Currently, there are many different surgical approaches to orbital pathology. This pathology rarely occurs in neurosurgical practice, and neurosurgeons have often used approaches that can be accompanied by negative cosmetic and functional outcomes.

MATERIAL AND METHODS

We present a case report of orbital cavernoma removal via a minimally invasive approach.

RESULTS

The presented case demonstrates successful removal of orbital cavernoma using the transpalpebral approach: a skin incision along a natural fold of the upper eyelid and orbitofrontal keyhole craniotomy. In the postoperative period, existing symptoms regressed; the patient assessed the cosmetic effect as excellent.

CONCLUSION

The transpalpebral keyhole approach can be an excellent alternative to traditional approaches to orbital cavernomas. This approach demonstrated its efficacy and safety in skull base surgery and provided excellent functional and cosmetic outcomes.

A Modified Lateral Orbitotomy Approach to the Superior Orbital Fissure: A Video Case Report and Review of Anatomy

BACKGROUND

The lateral orbitotomy approach (LOA) is often used for accessing the orbital contents and middle skull base; however, most prior descriptions of the LOA involve complete drilling of the lateral orbital wall. This practice requires retraction of the orbital contents and produces postoperative diplopia that the patient experiences for a limited time.

OBJECTIVE

To describe a modified LOA with partial sparing of the lateral orbital wall for accessing lesions of the superior orbital fissure (SOF).

METHODS

One patient with a progressively enlarging SOF lesion and visual loss underwent a modified LOA for resection. The orbital rim lateral to the SOF was removed as a bone flap, and the greater wing of the sphenoid inferior to the SOF was drilled to expose the lesion. The lateral orbital wall was thinned but was not completely removed. The orbital rim was resecured with miniplates and screws.

RESULTS

Gross total resection of the SOF mass was achieved without unnecessary exposure or retraction of the orbital contents. Histopathologic analysis of the resected mass was consistent with a cavernous hemangioma. The patient had a good cosmetic outcome without complication.

CONCLUSION

Modified LOA with partial sparing of the lateral orbital wall is a feasible approach for lesions of the SOF.

Surgical Orbital Anatomy

In this article, the anatomy of the orbit is reviewed, with a specific emphasis on surgical anatomy. A brief discussion of the ocular globe is also included. The orbits are pyramidal structures separating the upper and middle facial skeletons. The walls, apex, and base harbor several foramina and fissures as well as bony irregularities where various ligaments, muscles, and capsules attach. There are a variety of surgical approaches to the orbit, including the traditional transcutaneous and neurosurgical techniques and, more recently, minimally invasive, endoscopic approaches.

Navigation-Guided Endoscopy Combined with Deep Lateral Orbitotomy for Removal of Small Tumors at the Lateral Orbital Apex

Purpose

To evaluate the efficacy, feasibility, and safety of the navigation-guided endoscopy combined with deep lateral orbitotomy for removal of small tumors at the lateral orbital apex.

Design

A retrospective, noncomparative case series.

Methods

Retrospective analysis of ten patients (10 eyes) with small tumors at the lateral orbital apex comprised navigation-guided endoscopy combined with deep lateral orbitotomy at the Eye Hospital of Wenzhou Medical University from November 2015 to November 2017. In each case, the indication of surgery was existing or imminent visual impairment due to the tumor. The removal was believed to be complete if the mass was removed intactly during the surgery. The tumor character was confirmed by pathological examination after surgery. Patients were followed up to 3 months after surgery. Best corrected visual acuity before and after surgery was compared.

Results

All tumors were completely removed by the navigation-guided endoscopic approach. The mean preoperative best corrected visual acuity was 6/15 (95% confidence interval (95% CI) 6/40–6/8.5), and the mean postoperative best corrected visual acuity was 6/10 (95% CI 6/15–6/7.5). 5 of 7 (71%) patients with vision loss gained visual improvement in different degrees after surgery, and the rest of the patients had preoperative best corrected visual acuity. Visual field of all patients also improved. 8 cavernous hemangiomas and 2 schwannomas were confirmed postoperatively by pathology. 4 patients accompanied with limitation of eye abduction, which recovered spontaneously in an average of 4 weeks. No other serious complications occurred.

Conclusions

Navigation-guided endoscopy combined with deep lateral orbitotomy seems to be a feasible, efficient, and safe approach for removing small tumors at the lateral orbital apex. This trial is registered with ChiCTR1800019244.

Surgical anatomy of the cavernous sinus, superior orbital fissure, and orbital apex via a lateral orbitotomy approach: a cadaveric anatomical study

BACKGROUND

Tumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions.

METHODS

Lateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections.

RESULTS

Changing the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit.

CONCLUSIONS

This approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.

Two- versus four-handed techniques for endonasal resection of orbital apex tumors

BACKGROUND

Open versus endonasal resection of orbital apex (OA) tumors is generally based on tumor size, location, and pathology. For endonasal resection, two- and four-handed techniques have been reported, but whether one technique is more optimal based on these tumor features has not been evaluated.

OBJECTIVE

To determine whether two- versus four-handed techniques result in better outcomes after endoscopic resection of OA tumors, and whether either technique is better suited for intra- versus extraconal location and for benign versus malignant pathology.

METHODS

A retrospective review of all expanded endonasal approaches for OA tumors was performed at a single institution from 2009 to 2013. A PubMed database search was also performed to review series published on endonasal OA tumor resection. Across all the cases reviewed, the following data were recorded: two- versus four-handed techniques, intra- versus extraconal tumor location, and benign versus malignant pathology. The relationship between these variables and resection extent was analyzed by the Fisher exact test. Postoperative visual status and complications were also reviewed.

RESULTS

Ten cases from the institution and 94 cases from 17 publications were reviewed. Both two- and four-handed techniques were used to resect extra- and intraconal OA tumors, for both benign and malignant pathology. Four-handed techniques included a purely endonasal approach and a combined endonasal-orbital approach. On univariate analysis, the strongest predictor of complete resection was benign pathology (p = 0.005). No significant difference was found between the extent of resection and a two- versus a four-handed technique. Visual status was improved or unchanged in 94% of cases, and other complications were rare.

CONCLUSION

Benign tumors that involve the medial extraconal and posterior inferomedial intraconal OA can be treated by either two- or four-handed endonasal techniques. Selecting two- versus four-handed techniques and endonasal versus endonasal-orbital four-handed techniques depends mainly on surgeons' experience. Endonasal approaches for malignant OA tumors are less likely to result in complete resection.

Novel Surgical Approaches to the Orbit

Determining safe surgical access to the orbit can be difficult given the complex anatomy and delicacy of the orbital structures. When considering biopsy or removal of an orbital tumor or repair of orbital fractures, careful planning is required to determine the ideal approach. Traditionally, this has at times necessitated invasive procedures with large incisions and extensive bone removal. The purpose of this review was to present newly techniques and devices in orbital surgery that have been reported over the past decade, with aims to provide better exposure and/or minimally invasive approaches and to improve morbidity and/or mortality.

Superolateral Orbitotomy for Intraorbital Tumors: Comparison with the Conventional Approach

Objectives This study aims to compare the surgical and functional outcomes of superolateral orbitotomy (group A) and conventional superior orbitotomy (group B) for benign orbital tumors. Design A retrospective review of 31 consecutive orbital tumor surgeries with the fronto-orbital approach was conducted. Setting Procedures were performed at two institutions by a single surgeon. Participants A total of 31 orbital tumor patients participated in this study. Overall, 11 intraconal and 2 extraconal tumors in group A and 11 intraconal and 7 extraconal tumors in group B were resected by superolateral orbitotomy, respectively. Main Outcome Measures Demographic information, pre- and postoperative neurological findings and neuroimaging data, and pathological data were collected. Surgical and functional outcomes were compared and statistically analyzed between the two different surgical procedures. Results The surgical outcomes were not significantly different between the two groups. In patients with intraconal tumors, the functional outcome was significantly better in group A than in group B. Conclusion Superolateral orbitotomy provides better functional outcomes.

Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas

The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.

Modified One-piece Supraorbital Approach for Orbital Tumors: Widely Preserved Orbital Roof in a Self-fitting Flap

Objectives The one-piece supraorbital approach is a rational approach for the removal of orbital tumors. However, cutting the roof through the orbit is often difficult. We modified the technique to facilitate the osteotomy and improve the cosmetic effect. Design Three burr holes are made: the first, the MacCarty keyhole (burr hole 1), exposes the anterior cranial fossa and orbit; the second is placed above the supraorbital nerve (burr hole 2); and the third on the superior temporal line. Through burr hole 2, a small hole is created on the roof, 10 mm in depth. Next the roof is rongeured through burr hole 1 toward the preexisting small hole. Seamless osteotomies using a diamond-coated threadwire saw and the preexisting four holes are performed. Lastly the flap is removed. On closure, sutures are passed through holes in the cuts made with the threadwire saw, and tied. Results We applied our technique to address orbital tumors in two adult patients. The osteotomies in the roof were easy, and most parts of the roof were repositioned. Conclusions Our modification results in orbital osteotomies with greater preservation of the roof. Because the self-fitting flap does not require the use of fixation devices, the reconstruction is cosmetically satisfactory.

Validity of the Lateral Supraorbital Approach as a Minimally Invasive Corridor for Orbital Lesions

BACKGROUND

Many approaches were recommended for surgical treatment of orbital lesions via either transorbital or transcranial routes. The frontolateral craniotomy through eyebrow skin incision (lateral supraorbital approach) is a combined cranio-orbital approach that could be used in different orbital lesions.

OBJECTIVES

To evaluate the efficacy and safety of the lateral supraorbital approach for resection of orbital lesions.

PATIENTS AND METHODS

Ten patients with different orbital lesions were treated by this minimally invasive technique. The technique is described in details. The postoperative outcome was evaluated with casting light on the specific parameters related to this approach.

RESULTS

This study included 6 females and 4 males, ranging in age from 2 years to 65 years with mean age of 37.3 years. Proptosis was the most common presenting complaint. Six patients were operated on via the right supraorbital approach, and 4 patients via the left supraorbital approach. Various pathological lesions were treated. The excision was total in 7 patients, subtotal in 1 patient, and partial in 2 patients. Two patients suffered transient supraorbital hypothesia, 1 patient showed temporary superficial wound infection with CSF leak and 1 patient died within 6 months.

CONCLUSION

The lateral supraorbital approach is a minimally invasive approach that provides excellent exposure of the superior, lateral, and medial orbit, as well as the orbital apex.

Multisession Gamma Knife Radiosurgery for Orbital Apex Tumors

OBJECTIVE

This study was performed to analyze the outcome of multisession gamma knife radiosurgery (GKS) in benign tumors located at the orbital apex.

METHODS

Medical records of 23 patients who underwent multisession GKS for benign orbital apex tumors were reviewed retrospectively. Three patients were diagnosed by histology, and the other 20 patients were given the diagnoses on the basis of clinical and radiological findings. Diagnoses included cavernous hemangioma (8 cases), meningioma (8 cases), and schwannoma (7 cases). All patients were treated with 4 sessions of GKS with 12 hours of interval. Median marginal dose in each session was 5 Gy (range, 4.5-5.5 Gy) at the 50% isodose line (range, 50%-55%).

RESULTS

Mean clinical and imaging follow-up duration after treatment were 52.1 and 34.2 months, respectively. Tumor control was achieved in 22 patients (95.7%). Significant tumor shrinkage was observed in 17 patients (73.9%), and mean tumor volume reduction rate was 53.9%. Visual function was improved in 16 patients (69.6%) and stable in 4 patients (17.4%). Deterioration of visual acuity was reported by 3 patients (13.0%). Clinical and radiological response to multisession GKS was most excellent in cavernous hemangiomas with tumor control in all patients, and the mean tumor volume reduction rate was 68.3%.

CONCLUSIONS

Multisession GKS proved to be an effective and safe management strategy for benign orbital apex tumors. Response to treatment was different according to the pathology, and multisession GKS may be considered as the initial treatment of choice for specific pathology such as cavernous hemangioma.

Transorbital approach without craniotomy to orbital tumors with extradural intracranial extension

PURPOSE

To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy.

METHODS

In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed.

RESULTS

Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6-74 years) and median follow-up time was 43.5 months (range: 3-148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0-2.6) to 0.1 (range: 0-2.6) at the last follow-up (p < 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p < 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months).

CONCLUSIONS

The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

"Round-the-Clock" Surgical Access to the Orbit

Objective To describe an algorithm to guide surgeons in choosing the most appropriate approach to orbital pathology. Methods A review of 12 selected illustrative cases operated on at the neurosurgical department of University of Pittsburgh Medical Center over 3 years from 2009 to 2011 was performed. Preoperative coronal magnetic resonance imaging and/or computed tomography views were compared using a "clock model" of the orbit with its center at the optic nerve. The rationale for choosing an external, endoscopic, or combined approach is discussed for each case. Results Using the right orbit for demonstration of the clock model, the medial transconjunctival approach provides access to the anterior orbit from 1 to 6 o'clock; endoscopic endonasal approaches provide access to the mid and posterior orbit and orbital apex from 1 to 7 o'clock. The lateral micro-orbitotomy gives access to the orbit from 8 to 10 o'clock. The frontotemporal craniotomy with orbital osteotomy accesses the orbit from 9 to 1 o'clock; addition of a zygomatic osteotomy to this extends access from 6 to 8 o'clock. Conclusions Combined, the approaches described provide 360 degrees of access to the entire orbit with the choice of the optimal approach guided primarily by the avoidance of crossing the plane of the optic nerve.

Endoscopic transconjunctival surgical approach to intraconal space of the orbit: first clinical experience

BACKGROUND AND PURPOSE

Recently, a transconjunctival, endoscope-assisted (TEA) approach to the medial intra-orbital space was developed based on cadaver preparations, with an ultimate goal of minimizing disturbances of the anatomic structures of the orbit. However, no report on clinical validation of this promising technique was published thus far. We present our experiences with the TEA approach in two patients.

MATERIAL AND METHODS

In emergency conditions, we approached the lateral retrobulbar space of a 42-year-old male through a 180° incision close to the corneal limbus; a scrap of metal, which had perforated the globe and resided at its posterior wall, was removed endoscopically. Moreover, we used the TEA approach to remove a tumor from the upper intraconal space in a 63-year-old woman.

RESULTS

In both patients the surgical goal was achieved with no muscle transection and without additional morbidity and complications.

CONCLUSIONS

Our experiences with TEA approach suggest that the procedure is clinically feasible, produces no co-morbidity and yields good functional and cosmetic results. As a result, the whole circumference of the retrobulbar space can be conveniently explored.

3T MRI and 128-slice dual-source CT cisternography images of the cranial nerves a brief pictorial review for clinicians

There is a broad community of health sciences professionals interested in the anatomy of the cranial nerves (CNs): specialists in neurology, neurosurgery, radiology, otolaryngology, ophthalmology, maxillofacial surgery, radiation oncology, and emergency medicine, as well as other related fields. Advances in neuroimaging using high-resolution images from computed tomography (CT) and magnetic resonance (MR) have made highly-detailed visualization of brain structures possible, allowing normal findings to be routinely assessed and nervous system pathology to be detected. In this article we present an integrated perspective of the normal anatomy of the CNs established by radiologists and neurosurgeons in order to provide a practical imaging review, which combines 128-slice dual-source multiplanar images from CT cisternography and 3T MR curved reconstructed images. The information about the CNs includes their origin, course (with emphasis on the cisternal segments and location of the orifices at the skull base transmitting them), function, and a brief listing of the most common pathologies affecting them. The scope of the article is clinical anatomy; readers will find specialized texts presenting detailed information about particular topics. Our aim in this article is to provide a helpful reference for understanding the complex anatomy of the cranial nerves.

Survey on the management of orbital and intraocular tumors among oculofacial surgeons in the Asia-Pacific region

A web-based anonymous survey was performed to assess the common practices of oculofacial surgeons in the management of orbital and intraocular tumors in the Asia-Pacific region. The questionnaire comprised a series of questions covering controversial topics sent via email to 131 oculofacial surgeons across 14 countries in the Asia-Pacific region. A total response rate of 61.7 % was achieved from May to December 2012. The most common benign orbital tumor was cavernous hemangioma (39.6 %) and the most common malignant orbital tumor was lymphoma (85.7 %). 40 % of surgeons recommended orbital radiation, for which the most common indications were thyroid eye disease (70.0 %) and malignancy (30.0 %). The most common orbitotomy approach was lateral (79.2 %). Most surgeons (87.1 %) offered enucleation for retinoblastoma, but there was also a significant proportion that offered chemoreduction with transpupillary thermotherapy or cryotherapy (58.1 %). Fewer surgeons offered brachytherapy (16.1 %) and intra-arterial chemotherapy (6.5 %). When performing enucleation for retinoblastoma, 81.8 % of surgeons performed a primary orbital implant placement. The most preferred type of implant was silicone/acrylic (90.2, 90.2 and 87.8 % for elderly, adults and children, respectively). The majority of surgeons used donor sclera (57.5 %) or no wrapping material at all (32.5 %). Almost all surgeons (95.1 %) did not drill and peg the implant for motility. We report the results of the first survey of oculofacial surgeons in the Asia-Pacific region on the management of intraocular and orbital tumors. In comparison with previous surveys performed in the USA and the UK, we found the practice patterns of the Asia-Pacific surgeons to be comparable.

Benign orbital apex tumors treated with multisession gamma knife radiosurgery

OBJECTIVE

The orbital apex is an important anatomic landmark that hosts numerous critical neurovascular structures. Tumor resection performed at this complex region poses a therapeutic challenge to orbital surgeons and often is associated with significant visual morbidity. This article reports the efficacy and safety of multisession gamma knife radiosurgery (GKRS) in benign, well-circumscribed tumors located at the orbital apex.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Five patients with visual disturbances resulting from a benign, well-circumscribed orbital apex tumor (3 cases of cavernous hemangioma and 2 cases of schwannoma).

METHODS

Each patient treated with GKRS with a total radiation dose of 20 Gy in 4 sessions (5 Gy in each session with an isodose line of 50%) delivered to the tumor margin.

MAIN OUTCOME MEASURES

Best-corrected visual acuity, visual field changes, orbital imaging, tumor growth control, and side effects of radiation.

RESULTS

All patients demonstrated improvement in visual acuity, pupillary responses, color vision, and visual field. Tumor shrinkage was observed in all patients and remained stable until the last follow-up. No adverse events were noted during or after the radiosurgery. None of the patients experienced any radiation-related ocular morbidity.

CONCLUSIONS

From this experience, multisession GKRS seems to be an effective management strategy to treat solitary, benign, well-circumscribed orbital apex tumors.

Combined endoscopic endonasal transorbital approach with transconjunctival-medial orbitotomy for excisional biopsy of the optic nerve: technical note

Background Access to the intraorbital optic nerve segment can be facilitated via a transcranial approach that allows access to the entire orbital cavity. The endoscopic endonasal approach (EEA) combined with a transconjunctival-medial orbitotomy represents an alternative technique to achieve the same goal.

Objective Report a surgical technique that allows total resection of the intraorbital optic nerve with minimal trauma and excellent results. Further extend and define the limits and indications of the EEA to orbital surgery.

Methods A patient with rapidly progressive, but asymmetric, vision loss underwent EEA for optic nerve biopsy. Due to the undetermined histopathological diagnosis and complete unilateral vision loss, diagnostic total optic nerve resection was indicated. The entire intraorbital length of the nerve was resected via an endoscopic endonasal transorbital approach combined with transconjunctival-medial orbitotomy.

Results A 2-cm intraorbital nerve segment was sent for pathological examination. The patient maintained normal extraocular movements and experienced no complications. The postoperative course was uneventful and the patient was discharged the next day.

Conclusion The EEA provides another option for access to the entire optic nerve. It is a safe and effective technique lacking cosmetic defects and providing an alternative corridor to traditional transcranial approaches to the orbit.

Comprehensive management of a rare carcinoma ex pleomorphic adenoma of the lacrimal gland with a modified lateral orbitotomy access osteotomy. A case report

BACKGROUND

Complete management of extraconal ocular tumors may require the joint efforts of a maxillofacial surgeon to provide access and an ophthalmic surgeon to completely excise the lesion. Pleomorphic adenoma is the most common benign tumor of the lacrimal glands, representing around 12% of the lacrimal fossa lesions. They may however undergo malignant changes. Carcinoma ex pleomorphic adenoma (CXPA), a type of malignant mixed tumor of the lacrimal gland has been rarely reported.

CASE REPORT

We report a case of CXPA of the lacrimal gland in a 35-year-old male. He was managed by a modified lateral orbitotomy access osteotomy with complete removal of the lesion and showed postoperative uneventful recovery.

DISCUSSION

Accurate clinical diagnosis of a neoplasm in the orbital cavity is important for correct therapeutic management. This paper emphasises on the comprehensive management of these lesions with a special emphasis on diagnosis and surgical technique.

[Therapy of tumors of the anterior orbit]

Tumors of the orbit are diagnosed on clinical and neuroradiological criteria. A biopsy may histologically confirm uncertain mass lesions. The patients' age and medical history predispose for certain tumor entities among the rather heterogenous spectrum of possible diagnoses. The therapy depends on the degree of malignancy and its location within the orbit. Among the different options, surgical excision is the most common followed by radiation therapy either in combination with surgery or alone. Chemotherapy plays a subsidiary role in certain lymphomas or metastases. This review covers the surgical techniques and treatment principles for tumors of the anterior orbit, explains radiotherapy techniques and briefly covers chemotherapy. Pediatric tumors of the orbit are covered separately.

Head and neck squamous cell carcinoma metastatic to the orbital apex

Primary squamous cell carcinoma of the head and neck most commonly metastasizes to the lymph nodes, lung, bone, and liver. Many other rare sites of metastatic disease have been reported. To date, metastatic squamous cell carcinoma of the head and neck to the orbital apex has not been described. Presented are two cases, one tonsil and one parotid primary with metastatic disease to the orbital apex. Many tumors have been found to metastasize to the eye and orbit, but head and neck neoplasms are rarely reported. A review of the literature is presented in addition to the detailed case reports with their radiologic findings and clinical course. Surgical resection followed by postoperative radiotherapy appears the treatment of choice at this time.

The palatal overlap flap: a modification of the maxillary swing procedure to prevent ascending infection

The maxillary swing procedure provides an excellent approach to the anterior skull base region and to the clivus. The osteotomy should not be standard; it should vary with the size and position of the central skull base tumor being resected. The main reason for publishing this article is to draw attention to a method of preventing ascending infection from the oral cavity to the intracranial area using the palatal overlap flap. Examples of this approach are provided.

Extended fronto-orbital approaches to the anterior cranial base: variations on a theme

Combined frontal, orbital and zygomatic osteotomies have expanded the skull base surgeon's repertoire of approaches to the anterior skull base. Techniques borrowed from craniofacial surgery provide for extensive exposure of the orbit and anterior fossa while minimizing brain retraction. This article emphasizes the variations on the theme of fronto-orbital craniotomy that allow this approach to be adapted to the precise location and extent of the lesion to be excised. Familiarity with these versatile techniques is an important part of the skull base surgeon's armamentarium.

Anteromedial approach to the orbit

This study evaluated the surgical results of the anteromedial approach for treatment of orbital lesions in 16 patients. Pre- and postoperatively, all patients underwent a complete physical examination focusing on the head and neck area including a thorough ophthalmologic evaluation, computerized tomography, and magnetic resonance imaging. The surgical approach was limited to a medial orbitotomy in five patients; the remaining 11 patients underwent a medial orbitotomy combined with an external sphenoethmoidectomy. The tumor was removed completely without damaging the intraorbital neurovascular structures in all but one patient whose recurrent clival chordoma extended beyond the limits of an extracranial approach. Fibro-osseous lesions, cavernous hemangiomas, and dermoid cysts were the most common pathologies. The follow-up ranged from 18 to 48 months, and no patient has shown evidence of a recurrence. One patient with a clival chordoma received radiation therapy. The lateral nasal skin incision healed with acceptable cosmetic results. The anteromedial approach to the orbit provides a wider working space and direct exposure while protecting neurovascular structures.

Primary intraorbital ectopic meningioma

We report a case of intraorbital meningioma. Operative findings and histopathological examination revealed the tumoc to be meningothelial meningloma and to be located entirely outside the optic dura. This case demonstrates the occurrence of primary intraorbital ectopic meningioma, and the tumor was removed through a modified Dolenc approach. The primary intraorbital ectopic meningioma is discussed and the surgical approach to the orbital apex region is reviewed.

Modified lateral orbitotomy approach: a novel technique in the management of lacrimal gland tumors

Lateral orbitotomy is a well-known approach in the surgical management of lesions in the lateral orbital regions. It is still appropriate for laterally situated tumors, although contemporary cranial base approaches were defined and developed within the last decades. The extent of lateral orbitotomy should depend on the size, consistency, and nature of the lesion for easy surgical removal and reconstruction thereafter. In this regard, contrast-enhanced computed tomographic scans provide useful information for operative strategy. Although there is a wide range of histopathologic diagnosis for orbital tumors, lateral orbitotomy is a safe approach, particularly if the lesions are extraconal. We present a case of pleomorphic adenoma of lacrimal gland managed by a modified lateral orbitotomy approach with pleasing results.

Surgical treatment of orbital cavernomas: clinical and functional outcome in a series of 20 patients

PURPOSE

The aim of this study is to assess the efficacy and safety of surgical treatment of orbital cavernomas in terms of clinical and functional results.

METHODS

Twenty consecutive patients underwent surgical removal of a unilateral orbital cavernoma between 1999 and 2009. Indications for surgical treatment were: visual impairment, diplopia due to ocular movement impairment, progressive and disfiguring unilateral proptosis, severe retroorbital pain clearly related to the orbital cavernoma. We used a topographic classification of the lesions within the orbit. The orbit has been divided into an anterior and a posterior compartment on the axial plane and into three sectors on the coronal plane. The proptosis was quantified on MRI scans.

RESULTS

The location of the cavernoma determined the choice of the surgical approach. We performed eight lateral orbitotomies and 12 fronto-orbito-zygomatic approaches. All the tumors were completely removed as assessed at follow-up MRI. We did not record any intraoperative or major postoperative complication requiring a reoperation. The postoperative visual acuity improved in four of five patients with visual impairment, it worsened in the other case. Proptosis improved in all the patients. Diplopia improved in four patients, and did not recover in another case.

CONCLUSION

Surgical treatment of symptomatic orbital cavernomas is safe and effective. Tumor location dictates the choice of surgical approach. Visual function and cosmetic result are the main parameters to evaluate the clinical outcome. Surgical approach and dissection technique are crucial in determining the visual outcome.

Lateral orbitotomy for removal of sphenoid wing meningiomas invading the orbit

OBJECTIVE

This study defines the indications, results, and limits of lateral orbitotomy coupled with resection of the sphenoid wing for removing lateral sphenoid wing meningiomas with intraorbital extension.

METHODS

Eighteen patients with lateral sphenoid wing meningiomas and tumor extension into the lateral or superolateral compartments of the orbital cavity were treated by microsurgical lateral orbitotomy and resection of the sphenoid wing without craniotomy. The approach consisted of a linear skin incision along the upper eyelid crease extending to 2 cm from the canthal angle and resection of the lateral orbital rim, lateral orbital wall, and infiltrated sphenoid wing.

RESULTS

A complete resection (Simpson I), including the infiltrated bone, dura, and periorbita, was obtained in 13 patients (72%); in the other 5 cases (28%), the tumor mass and most infiltrated dura were removed, but the entity of dural resection up to the normal tissue could not be exactly defined (Simpson II). Follow-up ranged from 5 to 17 years (mean 9.7 years).

CONCLUSION

A select group of lateral sphenoid wing meningiomas with tumor extension in the lateral or superolateral compartments of the orbital cavity may be successfully approached and removed through a lateral orbitotomy with resection of the sphenoid wing and without craniotomy. Cases with tumor extension to the anterior clinoid process and superior orbital fissure and those with extension medial to the axis of the optic nerve require a transcranial approach.

[Tumors and tumor-like lesions of the orbit]

This article gives an overview of the most common and clinically relevant tumors of the orbit and their treatment. The most common orbital tumors in childhood are cystic tumors, such as dermoid and epidermoid cysts. Capillary hemangiomas are the most common primary benign tumors of the orbit and appear mostly in the first year of life. In contrast teratomas are rare and histologically mostly benign. Neural tumors are, for example, gliomas of the optic nerve and in 25-50% of cases are associated with neurofibromatosis. Rhabdomyosarcoma is a rapidly growing malignant orbital tumor whereby the stage and localization are the most important prognostic factors for survival chance in children. Leukemia can be associated with a chloroma especially in the first decade of life. Lymphoproliferative diseases, vascular and cystic tumors in particular are known as tumors of adulthood. In addition to fibroosseous and mesenchymal tumors, neural forms, such as schwannomas are also important. Secondary tumors of the orbit are often manifested in the nose and paranasal sinuses.